Provider Demographics
NPI:1659173334
Name:DIXIE STREET DENTAL LLC
Entity type:Organization
Organization Name:DIXIE STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:HUNTER
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-909-5314
Mailing Address - Street 1:409 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3921
Mailing Address - Country:US
Mailing Address - Phone:770-834-9682
Mailing Address - Fax:
Practice Address - Street 1:409 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3921
Practice Address - Country:US
Practice Address - Phone:770-834-9682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental